Capsule commentary on Baier et al., A qualitative study of choosing home health care after hospitalization: the unintended consequences of 'patient choice' requirements.

Abstract

This study by Baier et al.1 sought to illustrate the decision-making process that occurs in hospital discharge planning when case managers engage with patients and families in selecting a home health agency. Case managers and home health consumers were qualitatively asked about their respective roles in the decision process, as well as their knowledge of existing public home health quality reports. No participants were aware of public quality reports. Case managers described presenting a list of available home health agencies to consumers, who in turn generally felt they had little information to guide their decision and often asked case managers for a recommendation. However, case managers felt unable to assist further in the process, citing federal laws protecting freedom of patient choice2 as preventing them from doing so. The major limitation in this study is the unexpected fact that none of the participants were aware of public quality reporting for home health agencies, effectively truncating the discussion to observations about how uninformed the decision-making process was and conjectures about how public quality reports might be used. While it is tempting to attribute case managers’ limited helpfulness in home health agency selection to the federal laws guaranteeing freedom of patient choice, the more immediate obstacle is a lack of awareness about the availability of a neutral source of quality reporting that consumers could directly access online. Other limitations include the lack of generalizability since participants were drawn solely from Rhode Island, and the relative lack of participants who were patients rather than family members. Not to its detriment, this study raises more questions than it answers. Future work could seek to test interventions in which quality reports are provided to home health consumers prior to their selection of an agency, with various patient-level and system-level outcomes3 compared against a control. In the larger context of transitional care,4 the relative importance of higher quality home health agency selection for patients post-discharge remains to be seen. Likely, the most effective interventions protecting patients in the transient period of increased vulnerability following hospitalization5 will be multifaceted.